Appeals Quality and Training Specialist - Remote - Martin's Point Health Care : Job Details

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of people caring for people, Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a Great Place to Work since 2015.

The Appeals Quality And Training Specialist supports the Appeals Department. This role supports Appeals quality goals through quality monitoring and training. This role partners directly with Appeals leadership to support on-going team development and growth. This role creates a training and accountability structure to ensure Health Plan departments meet customer service expectations as well as regulatory requirements.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

Maintains knowledge and general understanding of each line of business within Martin's Point Health Care, including Medicare Advantage, US Family Health Plan (USFHP).

Demonstrates advanced knowledge of enrollment / disenrollment guidelines, claims processing and plan benefits necessary to exercise decision-making authority to reprocess claims in accordance and alignment with regulatory and internal policies.

Independently and with judgement, conducts multi-faceted, complex investigations through claims review, provider credentialing, authorization processing, timeliness evaluations, and plan benefits design.

Prepares, executes, and documents internal appeals monitoring activities for each line of business.

Assists in development, revision, and/or review of internal departmental policies and procedures, in collaboration with appeals leadership and Compliance.

Identify, develops, and provides staff education/training related to appeals.

Maintains education, awareness, and knowledge of current appeals related regulations, best practices, and common audit findings.

Participant in process improvement opportunities to align procedures with policies and regulations.

Collaborates with leadership to provide feedback for identified process and/or performance gaps with the team.

Conducts daily, weekly and/or monthly appeal monitoring activities; Provides feedback to team members on a routine basis.

Serves as the subject matter expert for TRICARE and US Family Health Plan manuals related to appeals, as well as CMS Part C and Part D Organization Determinations and Grievances guidance.

Prepares files and participates in both internal and external auditing activities. These reviews may include activities like the Defense Health Agency (DHA) Annual review, NCQA certification audit, CMS Data Validation audits or CMS Full Program audits as well as ad hoc monitoring projects.

Independently partners with Medical Directors and other clinical support staff on appeals requiring clinical decision-making determinations.

Conducts routine data evaluation for identification of trends and opportunities for strategic or operational improvement across operational areas.

Supports new hire and annual training.

Supports investigation and resolution of appeals on as needed basis.

Represent the appeals function on corporate initiatives, projects, committees, as needed.

All other duties as assigned.

Education

• Bachelor's degree or equivalent combination of relevant education and experience.

Experience

• 3+ years of experience in the health insurance field.
• Proven experience and success in a mentoring role capacity

Skills

• Exceptional written and oral communication skills required
• Computer proficiency required in Microsoft Outlook, Word, Excel, TruCare and Salesforce. Experience with QNXT Claims Adjudication Platform strongly preferred.

Abilities

• Exceptional written and oral communication skills, with the ability to communicate complex information across all levels of the organization.
• Approach work assignments in an organized, process-focused manner, which fosters the achievement of effective results.
• Exceptional communication and interpersonal skills including problem-solving skills to collaborate effectively with diverse groups.
• In-depth abilities in collaboration, facilitation, strategic and creative thinking, and decision-making. (Required)
• Strong customer service orientation and demonstrated ability to establish and maintain trust and credibility with management and stakeholders. (Required)
• Ability to prioritize and multi-task while maintaining focus on department objectives
• Ability to work cooperatively with other departments
• Ability to function both independently and as a team
• Capacity to understand complex documents and translate to front line employees.
• Deadline and detail oriented
• Demonstrates an understanding of and alignment with Martin's Point Values and strategic goal

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.